Provider Demographics
NPI:1720307382
Name:ELLENSBURG CHIROPRACTIC,PS
Entity Type:Organization
Organization Name:ELLENSBURG CHIROPRACTIC,PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAVERO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-962-2225
Mailing Address - Street 1:109 S WATER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3061
Mailing Address - Country:US
Mailing Address - Phone:509-962-2225
Mailing Address - Fax:509-962-2270
Practice Address - Street 1:109 S WATER ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3061
Practice Address - Country:US
Practice Address - Phone:509-962-2225
Practice Address - Fax:509-962-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA111N00000X
WAMD00047820207LP2900X, 208VP0014X
208VP0000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty